Mysterious Abdominal Pain

Abstract

A man presented to the emergency room with recurrent episodes of abdominal pain. He had a history of coronary artery bypass grafting of the left internal mammary artery (LIMA) to the left anterior descending (LAD) artery and the right gastroepiploic artery to the posterior descending artery. After numerous gastrointestinal evaluations, a stress test was performed, which was positive. Coronary angiography showed a proximal occlusion of the LAD and right coronary artery and a normal functioning LIMA bypass. Aortography showed a 95% stenosis of the celiac trunk. Angioplasty and stent implantation of the celiac trunk was successfully performed. Six months later the patient was completely asymptomatic with a negative stress test. In conclusion, abdominal pain in patients who have undergone coronary artery bypass surgery using the right gastroepiploic artery should raise suspicion not only of a stenosis of the arterial conduit but also of a potential stenosis of the celiac trunk.KEYWORDS: Abdominal pain, coronary artery bypass grafting, right gastroepiploic artery, celiac trunk, angioplasty, stent implantation Recurrent abdominal pain is a frequent reason for patients seeking medical attention and may have a large differential diagnosis.1,2 In this case report, we describe a patient with recurrent abdominal pain where the initial interpretation of the symptoms was difficult but the final outcome was positive. CASE REPORTA 54-year-old man with hypertension and dyslipidemia presented to the emergency room with recurrent episodes of abdominal pain. He had a history of coronary artery bypass grafting of the left internal mammary artery (LIMA) to the left anterior descending artery (LAD) and the right gastroepiploic artery to the posterior descending artery.Clinical examination and basic blood work-up were normal. An abdominal ultrasound was performed because of a recent episode of pancreatitis. Gallstones were visualized in the gallbladder resulting in hospital admission and subsequent elective cholecystectomy. Unfortunately, his symptoms did not subside and thus a gastroscopy was performed that showed the presence of a hiatus hernia associated with initial signs of esophagitis but no gastric or duodenal pathologies. A breath test was also performed, confirming the presence of Helicobacter pylori, which was treated with omeprazole and amoxicillin for a month with subsequent confirmation of eradication.As symptoms still persisted, a stress test was performed which was positive with 2 mm ST-segment depression in the inferior leads. He therefore underwent coronary angiography that showed a proximal occlusion of the LAD and right coronary artery and a normal functioning LIMA bypass. During the same procedure, an abdominal aortogram was performed to visualize the major abdominal arteries and demonstrated a 95% stenosis of the celiac trunk (Fig. 1).